Executive Editor: Chris Colton

Authors: Dominik Heim, Shai Luria, Rami Mosheiff, Yoram Weil

Forearm shaft Multifragmentary, intact segmental fracture of one bone, fragmentary of the other

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Glossary

General considerations

Multifragmentary fracture of one bone and segmental fracture of the other are challenging and fortunately rare fractures. The injuries are often associated with limb-threatening soft-tissue compromise, including neurovascular deficits and compartment syndrome. The delicate balance between achieving restoration of limb alignment and stability while minimizing soft-tissue damage should be maintained. Although open reduction and plate fixation may be indicated in most of these fractures, other treatment methods should be considered as well.
In fractures where one of the bones has a segmental fracture pattern, the achievement of anatomical reduction and absolute stability may be possible in that bone, provided the soft-tissue envelope permits. However, in the presence of limb-threatening soft-tissue injury the achievement of this goal may not be possible.

Nonoperative treatment
Indication summary Skill Equipment
Severely injured polytrauma patients Basic surgical experience, no specialized skills Basic equipment only

In severely injured polytrauma patients, definitive fixation is delayed until physiological stabilization has been achieved. In the interim, the forearm and elbow should be placed in a well-padded splint. Neurovascular and muscle compartment status, and soft-tissue conditions should be closely monitored.

Nonoperative treatment may be necessary in patients who are medically unfit for surgery.

The outcome of nonoperative treatment of both bones fractures is usually suboptimal.

External fixation
Indication summary Skill Equipment
A means of temporary fixation for severely open fractures Some specialized surgical experience Simple surgical and imaging resources

External fixation can be indicated in severely open fractures. A monolateral frame configuration can be used on one or both bones, as a temporary means of treatment for these high energy fractures associated with compromised soft tissues. Alternatively, in experienced hands, ring fixators of the Ilizarov type can be used for the definitive fixation of these injuries; this requires a high level of expertise in this field. This method will not be considered here in any further detail.

Intramedullary nailing
Indication summary Skill Equipment
Irregular fractures with severe soft-tissue injury (see discussion) Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Nailing is the preferred option only in pediatric fractures. The role of intramedullary nailing in adult forearm shaft fractures is still to be defined. Rotational stability was long a limiting factor against the use of nails in forearm shaft fractures. Several locking options exist today and may lead to a wider use in forearm fractures in the future. So far, there is no strong evidence available to support nailing in most adult forearm fractures. Even though rotational stability is achievable nowadays, the risk of rotational malunion following closed reduction will persist. If there is poor soft tissue coverage, intramedullary nailing may offer some benefit.

Discussion of nailing in adult forearm shaft fractures is limited to multifragmentary fractures of both bones in AO Surgery Reference, until further evidence emerges.

Pediatric fractures are not included in this module of AO Surgery Reference.

ORIF - Plating
Indication summary Skill Equipment
Treatment of choice Highly experienced and skilled surgeon Simple surgical and imaging resources

Anatomical reduction and absolute stability can be achieved in the segmental fractures using compression plating. For fragmentary segmental fractures, bridge plating is used. The condition of the soft-tissue injury may preclude plating techniques.

Either conventional plates, or locked plates, can be used, if the principles of minimizing soft-tissue stripping and achieving both length and alignment are respected.

*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2013-07-09